CROMERR Application Cover Sheet

Non-Federal: State Environmental Agency Tribe Local Government Agency

Federal: EPA Program Proposal EPA Program Conformance Plan

Please do not use acronyms when completing this form

Primary Contact Information
First Name: / Last Name: / Position: / Agency:
Mailing Address (Street Address, Mail Code/Suite, City, State, Zip Code): / E-mail: / Primary Phone:
Fax: / Secondary Phone:
Secondary Contact Information
First Name: / Last Name: / Position: / Agency:
Mailing Address (Street Address, Mail Code/Suite, City, State, Zip Code): / E-mail: / Primary Phone:
Fax: / Secondary Phone:

This application requests modification/revision of the following authorized program(s):

40 CFR Part Authorized Program Title
For example:
40 CFR Part 142 - National Primary Drinking Water Regulations Implementation authorized program
*Be sure all of the associated reports listed on page 2 of the Application Cover Sheet/included in the application are covered under one of the authorized programs listed above.

This application addresses/includes (check or complete all that apply):

Priority Reports Non-Priority Reports New Systems Existing Systems

The OEI CROMERR application checklist is used for this application

Number of systems addressed in this application

Certifying Official
Certification of sufficient legal authority to implement electronic reporting by:
First Name: / Last Name: / Title: / Certification Date:
Copies of relevant laws and regulations establishing legal authority are included